Obamacare at Age 3: Still Too Young for Prognosis

The Affordable Care Act, the Obama administration’s signature attempt to broadly transform the health care system, marks its third anniversary this weekend. And it is still very much a toddler.

Advocates and opponents have been seizing on the anniversary to offer their assessments of the law. On Monday, the Health and Human Services Department took credit for the more than 100 million Americans who have received at least one free preventive health service because of the law. HHS Secretary Kathleen Sebelius started a Twitter stream (@acaturns3) where advocates can cheer. Meanwhile, critics have held several events to highlight the law’s potential costs to businesses and insurance purchasers.

Yet experts say it’s much too early to know how well the Affordable Care Act is meeting its dual goals of expanding health insurance coverage and reducing the growth of health care prices are working in practice. “It will not be fair to evaluate this law at all in 2014,” said MIT economics professor Jonathan Gruber, one of its architects.

Some provisions, such as the requirement that insurers cover preventive care, are in place. But most major components won’t kick in until next year, and there is much heavy lifting to be done between now and then. Here are some key elements yet to come.

Insurance Exchanges. The state marketplaces where individuals and small businesses must buy insurance are not yet built and stocked with products in most states. The prices of these products are also unknown.

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Medicaid. The Supreme Court’s decision upholding the law allows the states to decide whether to expand Medicaid coverage to a large pool of their low-income residents. Those decisions are still being debated, as governors negotiate with HHS and their legislatures, and wrestle with the politics of expansion.

Employer Mandate. The law will require all large employers to offer health coverage or pay a fine. Businesses are still waiting for key regulations and developing strategies to manage the costs of the options. Will employers drop coverage and dump workers on the exchanges? Will they cut back on employee hours or the size of their workforces? Too soon to tell.

Medicare. Will new payment systems, designed to reward quality health care over quantities of services, really work? Most are in their infancy. Though lots of providers have signed up for various pilot programs, it will take years to know whether the models succeed in lowering costs. The early signs are good. Medicare has grown more slowly than ever over the past three years. But some worry that the shift may be more about the weak economy than health policy.

Outreach. Even if the systems are perfect, they will rely on uninsured Americans learning about the new health care benefits and signing up. Early polling suggests this population will need a lot of education about the options and requirements. Sophisticated groups are working on this, but it’s a big and complex challenge.